Cultural issues during pregnancy

M Maldonado MD

Culture and Pregnancy

Cultural themes for pregnancy in “modern societies”

Cultural themes for pregnancy in “traditional societies”

Cultural themes for immigrants, usually from traditional to modern societies.

Culture and pregnancy

Little empirical evidence of problems or adaptive capacities is available

Cultural themes of pregnancy in modern societies have received little attention

Few studies in traditional societies, lack of resources

Some studies of immigrants, theme of “acculturation”

Culture and pregnancy in general

Pregnancy is a “vulnerable period”

Pregnancy is embedded in a cultural context

Pregnancy elicits responses (culturally

based) from the future parents and from

surrounding persons

Culture and pregnancy:common

concerns

Fear of negative outcome of pregnancy is

universal

Fear of damage to the baby or the mother,

to be prevented by maneuvers (diet, care,

etc.)

Wish for the baby to be healthy and to

thrive is universal.

Culture and pregnancy

The pregnant woman is in a special state and needs psychosocial assistance (if possible)

Transition to parenthood is a challenge for new parents, with each child

The baby (in utero and after birth) and the mother may suffer unique negative consequences from stress during this time

Intention to become pregnant?

How does the pregnancy come

about?

Pregnancy and intendedness

How did the pregnancy come about?

Is it a blessing or a burden?

What degree of control is possible about

whether one becomes pregnant

What is the reaction of other people to the

pregnancy

Abma et al, 1997

In US about 31% of pregnancies are

unintended (unwanted or wrong time)

In unmarried women 60% of pregnancies

are unintended

If unwanted pregnancy greater risks for the

health of the mother and the baby…

Peacock et al, 2000

Group studied by Peacock, USA, 83% of

African American women reported the

pregnancy was unintended

39% of Latino immigrant women reported

the pregnancy was unintended

Unintended pregnancy

Delay in seeking prenatal care and having a premature baby(Orr et al, 2001)

Higher risk of domestic violence

Higher level of stress and frequency of depression (Leathers and Kelly , 2000)

More likely negative attitude toward baby and abuse (Altemeir et al, 1984. Zuravinn, 1987

Traditional Little control is expected over one’s body

Almost no fore-planning

Pregnancy is a natural consequence

Higher powers may decide on whether pregnancy

or not

Pregnancy is the duty of women, particularly if

married, crowing of “womanhood”

Need of offspring

Traditional

The pregnancy is embedded in highly visible social matrix. Rituals around pregnancy

Consequences for the woman and her family

Socially prescribed ways of dealing with it , rules re. Eating, work, sexuality, need of support, hygiene, etc.

Modern

Pregnancy may or may not fit with the woman’s plans, separation between sexuality and pregnancy

Pregnancy is an individual’s responsibility

High degree of control is expected of one’s body

Social disapproval and special burdens for pregnancy out of wedlock and teenager

Modern

Pregnancy may be perceived as a

physiological process with little need of

special precautions

A woman may be encouraged to face

pregnancy alone and make plans by herself

High degree of independence and self-

sufficiency is expected

Immigrant woman or couple

There may be difficulty to carry out certain culturally prescribed practices ( e.g. dietary, massages, baths, etc.)

Maybe conflict over: abiding by cultural prescriptions or adopting a more modern attitude

Issues of betrayal, loss, nostalgia, or letting go of “old superstitions”.

How does one know if one is

pregnant?

How does one find out? And Who

does one tell?

Traditional

One finds out through a number of

culturally prescribed “signs”

Cravings, cessation of menstruation, mood

changes, a special feeling or look

One can be “partially pregnant” and

pregnancy is not only a physiological state,

but a continuum

Modern

Ostensibly a physiological phenomenon

“all or nothing” state

Pregnancy tests, urine tests, etc. are

emphasized

Still magical beliefs can underlie modern

beliefs.

Cultural response to pregnancy

NEWS OF BEING PREGNANT

When is one pregnant?

Can a woman be “partially pregnant”?

Some women report to have “the beginning “ of a

pregnancy

Does she/he rely on pregnancy tests of missed

periods

Who does she tell first and what does that mean?

Peacock et al. (2001) (USA)

Some Latino women “do not believe”

pregnancy tests

Latino women tend to rely more on signs

and symptoms rather than tests

More Afroamerican women experience

others discovering the pregnancy

Delay in recognition

Many women to avoid pressures to get

married or to face negative consequences

Avoid pressure to have abortion or to give

up baby for adoption

How should the baby be

delivered?

What are the best conditions for

delivery?

Traditional

Delivery is an affair mostly of women

Experienced woman, midwife or relative

assists in the birth

Men do not participate

Delivery may be dangerous and compared

to an heroic act

Deliveries (Latinamerica):

“epidemic” of C sections Comparatively high rate of C sections

Usual proportion in the world is 15% of deliveries

In Brazil it is around 30% and in some centers 50%

Middle and higher social class

Intolerance for pain, inconvenience, screaming etc.?

Cesarean sections

Osis et al, 2001. Women say they prefer

vaginal deliveries

Role of medical establishment in

prescribing C sections

Avoid complications and litigation,

conflicts with schedule

What are the dangers for a

pregnant woman/couple and

the baby? Culturally based prescriptions during

pregnancy

Traditional

Damage from multiple external causes

Less distinction between mind and body

Threats to the progression and survival

Reality of high infant mortality and of mortality

due to complications of delivery and pregnancy

Numerous extraneous dangers (supernatural,

invisible, spiritual)

Pervasive influence of envy

Traditional Danger of eclipses, lead to malformations

Danger of penetration by spirits, of ancestors or of animals, damaging the baby

Danger of witchcraft, evil influences from other persons (envy, evil eye, wish for a bad outcome)

Danger of bringing on bad luck, bragging, talking about infant prematurely, transgressing taboos

Dangers and concerns.

Avoid going to funerals (Vietnamese?)

Avoid reaching over one’s head (cord

around neck)

Avoiding drafts of air ( Haiti, Latinamerica,

Asian)

Avoid sexual intercourse ( several Asian

cultures and Latinamerican)

Dangers and concerns

Walking at certain times of day (

penetration by spirits)

Avoid certain people who have powers

Not talk about the baby before the birth, a

certain time, or not to mention the name

Not to have picture taken

FEAR of transgressing taboos

Traditional

Pregnancy is a special state, unlike any

other: e.g.

In some cultures a hot state, eating “hot”

foods, or avoid them (India?)

Obey “cravings” , avoid frustrations or baby

will have certain characteristics

Cravings and Pica

Women expect to have cravings.

In Saudi Arabia (Kanhal,1995) salty, milk products, sour foods,

Pica. In Afroamerican, eat corn starch, clay (Boyle and Mackey, 1999)

In US up to 65% of women may experience some pica (freezer ice, dirt, baking soda, cigarette butts. (Rumsey Coocksey, 1995)

Traditional

Alleviate work if possible

Not talking about the baby, not eliciting envy or

bringing on bad luck

Avoid “what people will say”, danger of “people

talking” ( Glass Coffin, 1991). “image management”

Using special protections, e.g metal against

eclipses, cord or red against evil eye, envy

Traditional

Avoiding frustrations and frightening experiences, e.g. “susto”

Being cared for by older women, e.g. mother in law or mother

Pregnancy is mostly a fortune and a blessing for the woman and her family

(a loss or a negative outcome may be a sign of punishment or inability to carry pregnancy successfully)

Modern

Danger of toxic waste, radiation, chemical substances, hormones in the food, etc.

Danger of use of substances (alcohol, cocaine, marijuana, etc.)

Danger of infections, malformations caused genetically or through mutations congenitally

Dangers mostly preventable and avoidable

Modern

Concerns related to access to health care

Affordability

Who will care for the baby?

Day care of staying home?

Value of motherhood vs. career and other

achievements are in conflict

Modern fears. E.g. Fear of aliens.

Modern

Taking vitamins and preventing some

malformations

Testing to determine if baby is normal

Ultrasound if possible to observe baby in

utero and possibly determining gender

Other tests to determine if baby under stress

or developing normally

Modern

Sexuality is independent of outcome

(mostly)

Exercise, healthy diet, some degree of work

are healthy

No smoking and avoiding man other

substances

Pregnancy and gender issues

Women’s issues

Gender of the baby

Gender of child

In many traditional cultures wish for a boy (

India, China, Latinamerica) for various

reasons (Patel et al, 2002)

Affirmation of masculinity, issue of dowry,

tradition, carrying the name, etc.

In Cambodia may be opposite

Domestic violence during

pregnancy

In an Indian study, 30% of women may be

abused during pregnancy (Jejeebhoy 1998 )

Also a high rate in Latinamerica ( Lartigue,

(Lartigue, 1998)

In the US and UK estimated 20 to 25% of

pregnant women are abused (Mezey & Bewley, 1997

) ( Petersebm 1997)

Pregnancy and depression

A study in Goa, 23% of women (270) had postnatal depression ( Patel et al, 2000)

A majority had depression even before the pregnancy. Only 22% of them developed the depression in the puerperium

Gender of the baby was a risk factor, as well as domestic violence and other well known factors.

In a study in South Africa (Cooper et al) also many women were depressed before pregnancy

Role of women in society?

Pregnancy and depression

In industrialized countries, risk factors,

social isolation and unsupportive husband

History of loss and deprivation, abuse

In some samples in inner cities depression

may reach 60 % or more of women

“war zones” in cities in US (Garbarino)

with high levels of violence, losses

Pregnancy and Migration

Issues of Acculturation and

Transculturation

Pregnancy and health system

Old and new practices

Modern society

Issues of access to food and to health care in

the US

Cost of prenatal care and of delivery

Quick discharge after delivery

Technological nature of pregnancy care

Traditional society

Experienced woman or “curandero” to tend

to pregnancy

In a survey in Denver (Padilla et al, 2001) suggests

30% of people have consulted a curandero.

95% know what it is.

Washington state survey, with foreign born

women (434), 21% have been to curandero (Skaer , 1996)

MIGRATION AND

PREGNANCY Traditional belief is that immigrants are at higher

risk of mental health problems

This is thought to be due to the effects of

migration, economic deprivation and loss (Escobar et

al, 2000)

At times, they have been thought to be

“defective” or backwards.

Industrialized countries are increasingly

“multicultural”

Migration and pregnancy

In the US Latinos are increasing in number steadily

By 2050 they will be 25% of the US population

The majority of Hispanics in the US are of Mexican origin

In some states they reach 25 to 30% of the population

Migration and pregnancy

Degree of “acculturation”

Embracing new values, new language, new

costumes and ways of behaving

For Mexican immigrant women, more

“acculturation” means worse outcomes in

terms of health and mental health (

substance use, alcohol abuse, etc.)

Acculturation

Measuring degree of acculturation in Latinos (Burnam et al. 1987)

Epidemiological Catchment Area study , of rates

of psychopathology in US. Related to Latinos:

Less acculturated people, less prevalence of

alcohol and drug abuse, phobia, antisocial

personality

Is there a selective effect of migrators?

Acculturation. National

Comorbidity Study

Rates of mood disorder in Latino population

Rates lower in Mexican born people vs. US

born Latino persons (Kessler et al, 1994)

Lower prevalence of substance abuse in the

Mexican born population

Mexican American Prevalence

Survey (Vega et al, 1998)

3000 adults in California

CIDI instrument (Composite Int. Diag.Interv.)

Rates of psychopathology are twice for US

born individuals

For women rates of alcohol and drug abuse

are 7x for US born women

Acculturation

Adoption of “new ways” , language, beliefs,

practices, while abandoning the old or

traditional ones.

Is acculturation adaptive? Is acculturation

beneficial for the health of pregnant

women?

Acculturation problems

In US Latino women who adhere to their traditional culture have more “positive health behaviors” (Ventura et al, 1997)

Less use of drugs and alcohol

Less complications during childbirth

Better perinatal health outcomes compared with more acculturated Latino women, diabetes, hypertension

US-Mexico Border study of

adolescents (Pumariega et al, 1992)

4000 adolescents, 11 to 18 years old

Rates of depression and distress (Panamerican

Youth Inventory and Center for Epidemiologic Studies Depressive

Scale)

Rate of drug abuse was 4x higher in US

born adolescents (21% vs 5%)

Higher levels of distress and suicidal

ideation in US born teenagers.

US Border…

Risk factors: More time watching television

Less time spent in family activities

Less involvement with friends

Less involvement in sports

U.California Irvine Mental Disorders in Primary

Care (Escobar et al, 1998)

1500 adolescents several groups

Mexican and Central American born :

Lower levels of posttraumatic disorder,

depression, panic disorder

Better levels of physical functioning

Higher rates of “somatization”

Pregnant Latina Women (Matson and

Rodriguez, 1999)

150 women, immigrant and US Born, rural

and urban

Highest rate of domestic violence in US

born rural Latina (highest level of

acculturation)

Latina women

More acculturated young Latina women

Start intercourse earlier in age

Higher rate of non-marital births (Loue, 1987)

Less acculturated Latino women..

Tend to enter later into health care system

in the US

Do not have a higher rate of premature

births

Do not have a higher rate of perinatal

mortality

Positive effect of traditional

culture?

Support network of extended family ,

traditional roles, use of cultural markers

and language (Escobar et al, 2000)

Social control exerted over health related

behaviors such as drug and alcohol use

Less isolation during pregnancy and

delivery